197610665-1-28-2025-31-AS-ASEA-DDCQJH-20250128111247

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610665
Report Date: 01/28/2025
Date Signed: 01/28/2025 11:13:04 AM

Document Has Been Signed on 01/28/2025 11:13 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	TML VILLA CANYON		FACILITY NUMBER:	197610665
ADMINISTRATOR/ DIRECTOR:	BOGOJE, KASEY		FACILITY TYPE:	772
ADDRESS:	27823 VILLA CANYON ROAD		TELEPHONE:	(855) 435-3801
CITY:	CASTAIC	STATE: CA	ZIP CODE:	91384
CAPACITY: 6		CENSUS: 0	DATE:	01/28/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Kasey Bogoje- Administrator		TIME VISIT/ INSPECTION COMPLETED:	11:30 AM

NARRATIVE

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On 1/28/25, at around 9:40 AM, Licensing Program Analyst (LPA) Angelica Segovia and Licensing Program Manager (LPM) Troy Agard conducted an announced Pre-licensing visit. LPA Segovia met with Administrator Kasey Bogoje.

An Initial license application to operate a Social Rehabilitation Facility, Short Term Residential Treatment Program was submitted to Community Care Licensing Division-CCLD on 09/04/2024,. The requested capacity is for six (6) ambulatory clients. Fire clearance was approved on 11/14/2024.

LPA conducted a physical plant tour and the following was noted:

Structure: The facility is a two-story building with three (3) bedrooms and three (3) bathrooms. No designated staff room.

Entrance: There is only one (1) entrance being utilized. Required postings such as: Personal Rights of Residents and visitation policy located in staff intake room.

Common Areas: These include the living room, dining room, group room, and staff intake therapy room. All common areas were observed to be neat, clean, and organized. All common areas were properly furnished and in good repair. The Staff intake/Therapy Room is located to the left upon entrance. The group room located to the right upon entrance will be used in unison of dining area when not having meals. The facility maintains a comfortable temperature of seventy-one (71) degrees. No firearms observed or will be maintained on the premises. There is currently no direct phone line on the premises.

Fireplace: LPA observed fireplace covered and inaccessible to clients.

Clients/staff files: Client and staff files will be kept digitally recorded on staff password protected computer inaccessible to clients.

LIC809C-continued

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TML VILLA CANYON	FACILITY NUMBER: 197610665
	VISIT DATE: 01/28/2025

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Kitchen: Sufficient supplies of seven (7) day nonperishable food was observed and Administrator will purchase and have readily available two (2) day perishable foods prior to clients’ arrivals. Kitchen counter-tops will be installed within the following weeks where sufficient supplies of dishes, cups, and silverware will be purchased and readily available for the clients upon arrival. Working stove and refrigerator observed and in proper condition.

Emergency: Fire extinguisher located upon entrance on the right side and dated 10/30/2024.

Medications: Medication will be stored in the medication supply storage closet located near the stairs leading towards the second floor. Medication storage is equipped with a lock to ensure medications will not be accessible to clients. First-aid kit observed as well.

Bedrooms: All three (3) bedrooms are located on the second floor. The bedrooms are properly furnished with bed, nightstand, applicable lightening, and seating. Window coverings are in good repair, not broken or damaged.

Bathroom: The bathrooms are in proper condition and will be equipped with sufficient personal hygiene for each client. Towels and washcloths will not be shared.

Hallways: Hallway is properly lighted. Extra linens/covers will be stored in storage closet upstairs leading towards bedroom three (3).

The Garage: The garage can be accessed from inside the facility. The garage will be used for extra storage, Cleaning solutions, Laundry detergents, extra food for emergencies, and extra personal hygiene supplies. There is an extra refrigerator observed.

Laundry: Laundry is located inside the garage. Dryer and washer observed to be in good repair.

Staff room: No designated staff room on premises.

Water Temperature: The water temperature was measured in both downstairs and upstairs bathrooms at a range of 113.4-118.0 Fahrenheit and is within regulations.

LIC809C-continued

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TML VILLA CANYON	FACILITY NUMBER: 197610665
	VISIT DATE: 01/28/2025

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Smoke detectors: Dual interconnected smoke detectors and carbon monoxide observed to be working properly and were tested at 10:00 am.

Outside: The outside is clean, free of hazards, and properly furnished with sufficient seating. A shaded area for clients was observed as well.

Pool: No body of water located on premises.

Administration: The facility had submitted a Emergency and Disaster Plan For Adult Community Care Facilities and Residential Care Facilities for the Chronically ill and Infection plan.

Administrator The Component III Orientation Adult Residential Facility (ARF) was shown/reviewed with the Administrator.

Facility is not yet in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB) once LPA receives photos of corrections. You will be notified by the CAB Analyst when your license has been approved.

List of photos to be submitted to LPA will be: Proof of removal of scrap metal from the backyard. Installation of Smoke Detector in garage, Installation of Locked cabinet within the garage for toxins and cleaning solutions, installation of kitchen counter-tops, and locked cabinet underneath kitchen sink for sharps and cleaning solutions. Video of direct working phone line will be sent to LPA.

Exit interview conducted and copy of this report issued to the administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025

LIC809 (FAS) - (06/04)

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